Prognostic factors for gallbladder cancer in the laparoscopy era / 대한외과학회지

PURPOSE: Hepatobiliary surgery has changed dramatically in recent decades with the advent of laparoscopic techniques. The aim of this retrospective study was to compare survival rates according to stages, adjusting for important prognostic factors. METHODS: A retrospective study of a 17-year period from January 1994 to April 2011 was carried out. The cases studied were divided into two time period cohorts, those treated in the first 9-years (n = 109) and those treated in the last 7-years (n = 109). RESULTS: An operation with curative intent was performed on 218 patients. The 5-year survival rates according to the depth of invasion were 86% (T1), 56% (T2), 45% (T3), and 5% (T4). The number of cases of incidental gallbladder cancer found during 3,919 laparoscopic cholecystectomies was 96 (2.4%). Incidental gallbladder cancer revealed a better survival rate (P = 0.003). Iatrogenic bile spillage was found in 20 perforations of the gallbladder during laparoscopic cholecystectomies, 16 preoperative percutaneous transhepatic gallbladder drainages and 16 percutaneous transhepatic biliary drainages; only percutaneous transhepatic biliary drainage patients showed a significantly lower survival rate than patients without iatrogenic bile spillage (P < 0.034). Chemoradiation appeared to improve overall survival (P < 0.001). Multivariate analysis also revealed that time period, type of surgery, surgical margin, lymphovascular invasion, lymph node involvement, and chemoradiation therapy had significant effects. CONCLUSION: This study found that the prognosis of gallbladder cancer is still determined by the stage at presentation due to the aggressive biology of this tumor. Early diagnosis, radical resection and appropriate adjuvant therapy can increase overall survival.

Intestinal Anastomosis by Use of a Memory-shaped Compression Anastomosis Clip (Hand CAC 30): Early Clinical Experience

PURPOSE: The safety and the efficacy of the compression anastomosis clip (Hand CAC 30) have been demonstrated by animal studies. This study was designed to evaluate the clinical validity of the Hand CAC 30 in enterocolic side-to-side anastomosis after colonic or enteric resections. METHODS: A non-randomized prospective data collection was performed for patients undergoing a side-to-side anastomosis using the Hand CAC 30. Eligibility criteria for the use of the Hand CAC 30 were for anastomoses between the colon and the ileum or between two small bowels. The primary short-term endpoint was the rate of anastomotic leakage. Other clinical outcomes, including intra- and postoperative complications, length of operation time and hospital stay, and the clip elimination time were recorded. RESULTS: A total of 63 patients (male, 36) underwent an enteric or right-sided colonic resection followed by a side-to-side anastomosis using the Hand CAC 30. Laparoscopic surgery was performed in 36 patients, in whom one patient who underwent a laparoscopic right hemicolectomy was converted to an open procedure (1/32, 3.1%). One patient with ascending colon cancer showed postoperative anastomotic leakage and died of co-morbid ischemic heart disease. There were no other surgical mortalities. The exact date of expulsion of the clip could not be recorded because most patients were not aware of clip elimination. No patients manifested clinical symptoms of anastomotic stricture. CONCLUSION: Short-term evaluation of the Hand CAC 30 anastomosis in patients undergoing enterocolic surgery proved it to be a safe and efficacious alternative to the standard hand-sewn or stapling technique.

Primary Repair of a Huge Incisional Hernia by Using an External Oblique Myofascial Releasing Technique without Mesh: A Case Report

Incisional hernias are one of the most common complications after abdominal surgery and are an important cause of postoperative morbidity. Various methods are available for repairing incisional hernias, such as primary suture repair, an open mesh technique, and a laparoscopic mesh technique. The surgical management of a large incisional hernia by using a prosthetic mesh in a contaminated operative field (i.e., opened bowel from previous stoma or bowel resection) remains a difficult challenge because the non-absorbable mesh used is accompanied by a potential risk of infection and its related morbidity. We present a case of a large abdominal-wall defect, which was corrected by utilizing an external oblique myofascial releasing technique without the use of mesh, in a patient with an incisional hernia coexistent with Hartmann's colostomy.

Traumatic Abdominal Wall Hernia (TAWH): A Case Study Highlighting Surgical Management

We report a rare case of traumatic abdominal wall hernia (TAWH) caused by a traffic accident. A 47-year-old woman presented to the emergency room soon after a traffic accident. She complained of diffuse, dull abdominal pain and mild nausea. She had no history of prior abdominal surgery or hernia. We found a bulging mass on her right abdomen. Plain abdominal films demonstrated a protrusion of hollow viscus beyond the right paracolic fat plane. Computed tomography (CT) showed intestinal herniation through an abdominal wall defect into the subcutaneous space. She underwent an exploratory surgery, followed by a layer-by-layer interrupted closure of the wall defect using absorbable monofilament sutures without mesh and with no tension, despite the large size of the defect. Her postoperative course was uneventful.

Pancreatic Tuberculosis with Microcystic Adenoma

Tuberculosis of the pancreas is a rare disorder. The clinical presentation of pancreatic tuberculosis include nonspecific symptoms such as fever, fatigue and weight loss. The radiological features mimic pancreatic malignancy or pancreatitis. So, the diagnosis of pancreatic tuberculosis is very difficult. A 62-year-old man was referred for pancreatic mass. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, and fine needle aspiration test indicated microcystic adenoma or carcinoma. Pylorus-preserving pancreaticoduodenectomy was done. Final diagnosis was pancreatic tuberculosis combined with microcystic adenoma. We conclude in that patients who have a mass in the pancreas, pancreatic tuberculosis should be considered, particularly in the developing country and immunosuppressed individuals.

The Clinical Analysis of 25 Cases of Bezoars

PURPOSE: Bezoars are defined as retained concretions of animal or vegetable material in the gastrointestinal tract, and can be classified as trichobezoar, phytobezoar, trichophytobezoar or concretion. The purpose of this study was to review and analyze 25 cases of bezoar. METHODS: The medical records of 25 patients, treated between February 1995 and November 2004, were reviewed. The clinical characteristics, as well as the diagnostic evaluations and results of surgical treatment, were also analyzed retrospectively. RESULTS: Of the 25 patients, 13 men and 12 women, the bezoars were in the stomach, ileum or in both the stomach and ileum in 17, 5 and 2 cases, respectively, with 1 case in the esophagus. Bezoars are usually caused by an altered gastric physiology, with impaired gastric emptying as a result of surgery, such as subtotal gastrectomy, antrectomy or truncal vagotomy with pyloroplasty. The treatment of bezoars depends on their composition and location. A gastric bezoar can be treated by endoscopic removal, although not all cases can be completely removed. Small bowel bezoars are usually discovered on exploration due to an intestinal obstruction, with surgical removal being the standard treatment method in such cases. CONCLUSION: A bezoar occurs mainly in patients who have previously undergone a gastric operation. Surgeons should keep in mind the possibility of bezoars in patients presentingan intestinal obstruction following a past gastric operation. The treatment principle for bezoars used to be surgery, but recently gastric bezoars are often treated by gastrofiberscopy.

Prognostic Factors in the Patients Undergoing Hepatic Resection for Colorectal Liver Metastasis: Human Telomerase Reverse Transcriptase (hTERT), Ki-67 and p53 Expression

PURPOSE: We evaluated the expressions of hTERT, Ki-67 and p53 in patients who underwent a curative resection for hepatic colorectal metastasis to see if there was any relationship of these immunohistochemical analyses with the disease free survival. METHODS: Patients who underwent a curative resection for hepatic colorectal metastasis, between 1995 and 2003, were analyzed. For each patient, the clinical prognostic score was derived from the patient's sex, age, tumor size and lymph node status, and serum CEA level. Tumor specimens were analyzed for Ki-67, hTERT and p53 using standard immunohistochemical techniques. RESULTS: The study included 23 patients: 9 and 12 survived without disease for less and more than 12 months, respectively. Ki-67, hTERT (labeling indexes greater than or equal to 50%) and p53 positivities (labeling indexes greater than or equal to 10%) were observed in 5, 17 and 11 patients, respectively. CONCLUSION: In patients undergoing resection of hepatic colorectal metastasis, the expressions of Ki-67, hTERT and p53 did not correlate with the disease free survival.